ED Coding and Reimbursement Alert

Congress holds the bag on the SGR fix which could make or break your bottom line next year. 

CMS released the final rules for the 2015 Medicare Physician Fee Schedule and OPPS payments on October 31st, but there were few scares for the coming year. 

Here’s the Big Picture

Each year CMS publishes an estimate of the expected change in payments by specialty, based on the changes to be implemented in the physician fee schedule final rule. For 2015, that estimate is that emergency medicine will experience a 1 percent increase in overall Medicare payments, says Michael A. Granovsky, MD, FACEP, CPC, President of Logixhealth, a national ED coding and billing company based in Bedford, MA. 

Background: The work RVUs, which make up about 70 percent of total ED E/M RVUs, remain unchanged, but slight variations in the practice expense and professional liability insurance (PLI) RVUs are the reason for the slight increase.  Medicare law requires review, and if necessary, adjustment of PLI RVUs no less often than every five years, Granovsky says. For 2015, CMS conducted the third comprehensive review and update of the malpractice RVUs and proposed new malpractice RVUs for all services, he adds. CMS is adopting new PLI RVUs based on updated professional liability insurance premiums, which make up most of the increases for the ED E/M codes.  

$$$ for ED: Even at only 1 percent, emergency medicine is tied for the highest expected payment increase of all medical specialties, Granovsky adds.

Wait for Congress SGR Reprieve

In spite of this ED boost, we can’t forget the looming shadow of the formula driven sustainable growth rate (SGR) cuts to the Medicare conversion factor. Unless Congress steps in with a permanent fix, or at least another patch to delay implementation, as it has every year since 2002, Medicare payments will be cut by 21 percent in 2015. 

You may recall that the Protecting Access to Medicare Act (PAMA) of 2014 provides for a zero percent physician fee schedule update for services furnished between Jan. 1, 2015 and March 31, 2015, so we have a few months for Congress to act in early 2015 and still avoid the payment cuts.

Conversion factor limbo: PAMA also provides for a 0.0 percent update to the fee schedule for services furnished on or after Jan. 1, 2015 and on or before March 31, 2015. However, the final rule outlines a small decrease from the 2014 Medicare Conversion Factor of $35.822 to $35.8013 for the PAMA period of Jan. 1 through March 31, 2015. If no SGR reprieve is in place by that time, the conversion factor is scheduled to drop to $28.2239 beginning in April 2015. If Congressional tradition holds, that drastic cut will not occur, Granovsky predicts. 

GPCIs Expire for All But Protected States 

Although the statutorily mandated 1.5 work GPCI floor in Alaska, and the 1.0 PE GPCI floor for frontier states (Montana, Nevada, North Dakota, South Dakota, and Wyoming) are not in play, the temporary 1.0 work GPCI floor for all other physician fee schedule areas is scheduled to expire under current law on March 31, 2015. The GPCIs in the final rule reflect the elimination of the 1.0 work GPCI floor from April 1, 2015 through December 31, 2015, says Granovsky.

Some Good News on Physician Expense Trends

The final rule gives some hope that a permanent fix may be possible in that for the first time since the year 2000, both actual expenditures and cumulative allowed expenditures for physician practices were below lower than the respective allowed expenditures.  

Because this makes five consecutive years of actual expenditures coming in below the budgeted allowed expenditures for that period, it should lower the cost of a true SGR fix. That savings may make a permanent fix, rather than a patch more acceptable to Congress, says Granovsky.

End in Sight for Global Periods 

The final rule also clarifies CMS’ intent to phase out global surgical packages for 10- and 90-day global periods. Procedures with 10-day global will transition to zero day global periods in 2017. 

We saw a similar change with the simple laceration repair codes in 2011, and might see similar revaluation (starting at about 40 percent) with the rest of the 10-day global codes. Codes with current 90-day global periods are scheduled for transition to zero day globals beginning in 2018. At that time, Medicare intends to pay separately for all follow up visits and services related to the procedures in question.  

Reason: The rationale for the change is that the current global payment structure no longer accurately values resources expended in care for these patients, Granovsky explains.

Get the Scoop on New Chronic Care Management Payment 

Medicare continues to emphasize primary care by making payment for chronic care management (CCM) services – non-face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – beginning in 2015. Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management, which are not typically provided by emergency physicians. 

CMS has established a payment rate of $40.39 for CCM that can be billed up to once per month per qualified patient, says Granovsky.

Watch for New Modifier For Off-Campus Provider-Based Departments

CMS will collect data on services furnished in off-campus provider-based departments by requiring hospitals to report a modifier for those services furnished in an off-campus provider-based department of the hospital and by requiring physicians and other billing practitioners to report these services using a new place of service code on professional claims. 

Data collection will be voluntary for hospitals in 2015 and required beginning on Jan. 1, 2016. The new place of service code will be required for professional claims as soon as it is available, but not before Jan. 1, 2016.

This 2-digit modifier will be added to the HCPCS annual file as of January 1, 2015, with the label “PO,” the short descriptor “Serv/proc off-campus pbd,” and the long descriptor “Services, procedures and/or surgeries furnished at off-campus provider-based outpatient departments.” Reporting of this new modifier will be voluntary for 1 year (CY 2015), with reporting required beginning on January 1, 2016.

ED exempt: The final rule makes it clear that the emergency department with place of service 23 will not be subject to this rule, says Granovsky. 

Value Modifier Payment Adjustments

CMS previously established CY 2015 as the reporting period for the CY 2017 payment adjustment period for the Value Modifier. It will increase the maximum amount of payment at risk from -2.0 percent to -4.0 percent only for groups with ten or more eligible providers (EPs). 

That is, for CY 2017 payments, a -4.0 percent Value Modifier adjustment will apply to groups of ten or more EPs subject to the Value Modifier that do not meet the quality reporting requirements for the Physician Quality Reporting System (PQRS).

Quality Tiering Makes A Big Impact

If your ED group satisfies the PQRS reporting requirements, the next step in the process is quality tiering. 

CMS will increase the maximum downward adjustment under the quality-tiering methodology for groups with ten or more EPs to -4.0 percent for classified as low quality/high cost and set the adjustment at -2.0 percent for groups classified as either low quality/average cost or average quality/high cost. 

On the positive side, CMS will also increase the maximum upward adjustment under the quality-tiering methodology in the CY 2017 payment adjustment period to +4.0x for groups of ten or more EPs classified as high quality/low cost and set the adjustment to +2.0x for groups of ten or more EPs classified as either average quality/low cost or high quality/average cost, says Granovsky. 

The table below illustrates the 2017 quality process for groups with 10 or more eligible providers:

Expanded Informal Inquiry Process

CMS will expand the informal inquiry process for the Value Modifier starting with the CY 2015 payment adjustment period. The agency will establish a brief period for a group or solo practitioner to request correction of a perceived error made by CMS in the determination of its Value Modifier payment adjustment.

PQRS Payment Adjustments Are Only Negative Now

In 2015, a downward payment adjustment will apply to eligible providers who do not satisfactorily report data on quality measures for covered professional services or satisfactorily participate in a qualified clinical data registry (QCDR). In the 2015 PFS final rule, CMS establishes requirements primarily related to the 2017 PQRS payment adjustment.

For the 2017 PQRS payment adjustment, CMS has established criteria for satisfactory reporting and satisfactory participation that are generally similar to the criteria it finalized for the 2014 PQRS payment incentive, Granovsky explains.

If you want to avoid a payment adjustment in 2017, heed these requirements:

• Eligible professionals and group practices reporting via claims or registry who see at least one Medicare patient in a face-to-face encounter should report on at least one measure from a newly cross-cutting measures set in addition to any other measures that the eligible professional is required to report.
• All group practices of 25 or more eligible professionals using the group payment reporting option (GPRO) web interface should report measures on a beneficiary sample of 248 patients.
• All group practices of 100 or more eligible professionals that are registered for the GPRO should report on the Consumer Assessment of Healthcare Provider and Systems survey CAHPS for PQRS regardless of the reporting mechanism the group practice chooses. The group practices will bear the cost of administering CAHPS for PQRS.